Melaena

I went in late for the ward round in Chorley this morning at about 1030am and the patients were shifted to a brand new ward and it took me some time to figure out where the new ward is. So finally i was in the ward and trying to catch up from the ward round as i have not been into the ward for 2 weeks. Then the crash alarmed just rang and i didnt know that was the carsh alarm... (How stupid am i....) But i could figure out something wrong happened as the staffs including all the doctors ran towards one of the pateint. Then i tried to have a look but unfortunately the nurses responded quickly by pulling up the screen. I just stood there and didnt know what should i do... ( i think i look stupid that time...)
Because we were all in the new ward, the doctors were looking for gloves and the crash trolley. One of the nurse brought in the Obs monitor. The nurse then pushed out the wheel chair that had a bowl that was conveneint enough for immobile patient to pass motion. And on that wheel chair i could see stain of melaena (blood mixing with stool)... Oh dear, the patient has got some sort of GI bleed... I tried to peep in through the curtain, then i could see the patient lying on the floor with pool of melaena that dirty the floor and her clothes. I could hear the doctor said that she wasnt arrested but she was collapse after opening her bowel. (probably due to vasovagal response plus acute blood loss.)
Matt and Ross were with me that time, Matt went to get gloves, Ross went to look for the patients notes, and me stupidly standing there, couldnt do anything... So my Reg asked the nurse to get some fluids for resuscitation . After stabilising the patient, he went to arrange an urgent endoscopy. Then my SHO was there to trying to get the patients up and examine her again to make sure she's had not injured herself from falling just now. The FY1 was taking her blood and now i finally have some role in the whole picture... I helped the FY1 to send the blood to the lab( the blood was taken at 1130am and came back with the result of Hb 6.1)
So... we tried to check the history of the pateint. She initially came in with falls and developed episode of ? haemoptysis ?hematemesis last saturday. (But considering she had melaene, she could have had hemetemesis) But no history of taking NSAIDs which put her at risk of develping GI bleed. She already had 2 units of blood transfused that time. So we followed her through to the endoscopy unit. Upon endoscopy, 2ulcers were found that are actively bleeding. The surgeon who conducted the endoscopy injected 6ml of Adr to try to constrict the vessels and reduce the bleeding, and applied clips twice to stop the bleeding. He managed to stop the bleeding of one of the ulcer and slow down the bleeding from another ulcer. In short, the patient's still bleeding. He said that the patient would need surgical intervention as there wasnt much could be done endoscopically. A gastroenterologist came in to review her and agreed with the surgeon but.... considering that patient is 80 year old and she has pulmonary fibrosis... So she might be at some risk for anaesthtics.
Now the issue is to refer her to Preston (which has better ITU care considering that the patient might need it after surgery) or do the surgery in Chorley (as she might not be fit for transferring). After viewing the pros and cons, discussing with the surgeon and anaethetist, the decision was... Refer the pateint to Preston for emergency surgery. Meanwhile, IV omeprazole was prescried for her since she has got 2 big ulcers. So the paramedics came up and Matt and I decided to follow the pateint through and hopefully we could go into the theatre and see how would the surgery be carried out. Matt spoke to the paramedics and we actually went onto the ambulance with this patient. Matt was carrying the blood box (at this time, i think the patient is transfusing her 4th unit of blood) and i was holding my notes and we set off from Chorley to Preston. When i was in the ambulance, i felt that i was one of the movie star in some show...rescuing patient in something goes wrong on the ambulance... hahaha... in fact, i did nothing. coz the patient was stable and alert and she looked quite well..
It only took us 10min to reach the hospital, (normally the shuttle takes 20min) we reached at 3pm. The pateint was sent to SAU and we waited with her for the surgeon and anaesthetist to come and review her. And after all the hassles, the patient was finally sent to the theatre at 5pm. And the surgeon open up her duodenum and showed us the ulcers. The bleeding was stopped already by that time. They stitched up the ulcers to prevent recurrent bleeding. And by that time, it was already 630pm. And we didnt have any lunch yet, we asked to go off and i was just very excited that i could have such a precious experience. Thanks to Matt!!!
So i will probably drop by to ITU tommorrow to find out how the patient do post-operatively. But this is it... Melaena, once you see it, you'll never forget!!!